(A) The bureau shall determine fee payments to an MCO that is selected by or assigned to employers with zero payroll, noncomplying employers, employers who are no longer in business, new employers, and other employer situations in which the employer's premium does not adequately account for an MCO's medical management services.
(1) If the employer did not have coverage with the state insurance fund for the full prior rating year, the bureau will annualize the premium.
(2) If the employer has zero payroll or did not have coverage with the state insurance fund during the prior rating year, the bureau will estimate the annual premium.
(B) The bureau shall pay an MCO for its medical management and administrative services and may pay an MCO a performance incentive payment. The percent of premium multiplied by the total premium of the employers serviced by an MCO is the total eligible payment to an MCO.
(1) The applicable premium to serve as the basis for calculating the administrative fee to the MCO during a rating year shall be the employer's premium associated with its immediately preceding rating year as provided by rule 4123-17-01 of the Administrative Code. The bureau shall calculate premium for the prior rating year as reported on payroll reports. If the initial implementation of the HPP starts subsequent to July first for private employers and public employers state agencies or subsequent to January first for public employer taxing districts, the bureau shall prorate the MCO administrative fee for that partial rating year based on the premium for the immediately preceding rating year. Thereafter participation will be on a full rating year basis.
(2) The administrative payment shall be calculated as a fixed percentage of the total eligible payment to an MCO.
(3) The performance incentive payment may be paid from a performance incentive pool after evaluation of an MCO's services under the HPP in accordance with the evaluation criteria in paragraph (C) of this rule. An MCO shall compete for the performance incentive payment based upon objective performance measures that reduce costs while achieving quality medical care and outcomes and return employees to work safely.
(C) In establishing performance measures, the bureau shall take into account inherent industry hazards. The bureau shall evaluate an MCO's performance based upon but not limited to:
(1) Quality performance measures that may include return-to-work rates and reinjury rates.
(2) Total cost measures that may include average total paid cost, average incurred cost, and lost-time claims to total claims ratio.
(3) Change in cost measures that may include change in average total paid cost, change in average incurred cost, and change in lost-time to total claims ratio.
(4) Customer satisfaction that may include in-network utilization rate and employee, employer, and provider satisfaction surveys.
(D) The MCO application for certification and/or MCO contract shall set forth the performance incentive measures, criteria, weightings and/or adjustment factors, and other control factors.
Effective date: Feb. 16, 1996